Healthcare Provider Details

I. General information

NPI: 1104153543
Provider Name (Legal Business Name): RENE ALFREDO FAGALDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 BROOK RD
RICHMOND VA
23227-4143
US

IV. Provider business mailing address

3930 BROOK RD
RICHMOND VA
23227-4143
US

V. Phone/Fax

Practice location:
  • Phone: 804-517-9428
  • Fax: 804-262-1033
Mailing address:
  • Phone: 804-517-9428
  • Fax: 804-262-1033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: